24 Month Questionnaire

On the following pages are questions about activities children do. Your child may have already done some of the activities described here, and there may be some your child has not begun doing yet.
For each item, please check the box that tells whether your child is doing the activity regularly, sometimes, or not yet.

Important points to remember:

Be sure to try each activity with your child before checking a box.

Try to make completing this questionnaire a game that is fun for you and your child.

Make sure your child is rested, fed, and ready to play.

If you have any questions of concerns about your child or about this questionnaire, please call our office at (919) 460-0993.

Look forward to filling out another questionnaire in six months.

Child's Full Name:

Child's Gender: Male Female

Child's Date of Birth:

Child's corrected date of birth (if child is premature, add weeks of prematurity to the child's date of birth):

Today's Date:

Person filling out this questionnaire:

What is your relationship to the child?:

Home phone number:

Other phone number:

Your mailing address:

City:
State:
Zip:

Email Address:

Administering program or provider:

List of people assisting in the questionnaire completion:

Communication

Be sure to try each activity with your child.

YES

SOMETIMES

NOT YET

1. Without showing her first, does your child point to the correct picture when you say, "Show me a kitty" or ask "Where's the dog?" (She only needs to identify one picture correctly.)

2. Does your child imitate a two-word sentence? For example, when you say a two-word phrase, such as "Mama eat," "Daddy play," "Go home," or "What's this?" does your child say both words back to you? (Check yes even if his words are hard to understand)

3. Without giving her clues by pointing or using gestures, can your child carry out at least three of these kinds of directions?

a. "Put the toy on the table."

d. "Find your coat."

b. "Close the door."

e. "Take my hand."

c. "Bring me a towel."

f. "Get your book."

4. If you point to a picture of a ball (kitty, cup, hat, etc.) and ask your child, "What is this?" does your child correctly name at least one picture?

5. Does your child correctly use at least two words like "me," "I," "mine," and "you"?

6. Does your child say two or three words that represent different ideas together, such as "See dog," "Mommy come home," or "Kitty gone"? (Don't count word combinations that express one idea, such as "Bye-bye," "All gone," "All right," "What's that?")

Please give an example of your child's word combinations:

Communication Total:

Gross Motor

Be sure to try each activity with your child.

YES

SOMETIMES

NOT YET

1. Does your child walk down stairs if you hold onto one of his hands?

2. When you show her how to kick a large ball, does your child try to kick the ball by moving her leg forward or by walking into it? (if your child already kicks a ball, check "yes" for this item.)

3. Does your child walk either up or down at least two steps by himself? (You can look for this at a store, on a playground, or at home. Check "Yes" even if he holds onto the wall or railing.)

4. Does your child run fairly well, stopping herself without bumping into things or falling?

5. Does your child jump with both feet leaving the floor at the same time?

6. Without holding onto anything for support, does your child kick a ball by swinging his leg forward?

Gross Motor Total:

Fine Motor

Be sure to try each activity with your child.

YES

SOMETIMES

NOT YET

1. Does your child get a spoon into her mouth right side up so that the food usually doesn't spill?

2. Does your child turn the pages of a book by himself? (He may turn more than one page at a time)

3. Does your child use a turning motion with her hand while trying to turn doorknobs, windup toys, twist tops, or screw lids on and off jars?

4. Does your child flip switches off and on?

5. Does your child stack seven small blocks or toys on top of each other by himself? (You can use spools of thread, small boxes, or toys that about 1 inch in size.)

6. Does your child thread a shoelace through either a bead or an eyelet of a shoe?

Fine Motor Total:

Problem Solving

Be sure to try each activity with your child.

YES

SOMETIMES

NOT YET

1. After he watched you draw a line from the top of the paper to the bottom with a crayon, pen, or pencil, does your child copy you by drawing a single line on the paper in any direction? (Scribbling back and forth does not count as a "yes")

2. Without showing him how, does your child purposefully turn a small, clear bottle upside down to dump out a crumb or Cheerio? (You can use a soda-pop bottle or baby bottle.)

3. Does your child pretend objects are something else? For example, does your child hold a cup to her ear, pretending it is a telephone? Does she put a box on her head, pretending it is a hat? Does she use a block or small toy to stir food?

4. Does your child put things away where they belong? For example, does he know his toys belong on the toy shelf, his blanket goes on his bed, and dishes go in the kitchen?

5. If your child wants something she cannot reach, does she find a chair or box to stand on to reach it?

6. While your child watches, line up four objects like blocks or cars in a row. Does your child copy or imitate you and line up four objects in a row? (You can use spools of thread, small boxes, or toys that about 1 inch in size.)

Problem Solving Total:

Personal-Social

Be sure to try each activity with your child.

YES

SOMETIMES

NOT YET

1. Does your child drink from a cup or glass, putting it down again with little spilling?

2. Does your child copy activities you do, such as wipe up a spill, sweep, shave, or comb hair?

3. Does your child eat with a fork?

4. When playing with either a stuffed animal or doll, does your child pretend to rock it, feed it, change diapers, put it to bed, and so forth?

5. Does your child push a little shopping cart, stroller, or wagon, steering it around object and backing our of corners if he cannot turn?

6. Does your child call herself "I" or "me" more often than her own name? For example, "I do it," more often than "Juanita do it."

Personal-social Total:

Overall

Parents and providers may use the back of this sheet for additional comments.

1. Do you think your child hears well?

YES

NO

If no, explain:

2. Do you think your child talks like other toddlers his age?

YES

NO

If no, explain:

3. Can you understand most of what your child says?

YES

NO

If no, explain:

4. Do you think your child walks, runs, and climbs like other toddlers her age?

YES

NO

If no, explain:

5. Does either parent have a family history of childhood deafness or hearing impairment?

YES

NO

If yes, explain:

6. Do you have concerns about your child's vision?

YES

NO

If yes, explain:

7. Has your child had any medical problems in the last several months?